BMC Medicine BioMed Central

Research article Open Access

A systematic review of the incidence of schizophrenia: the
distribution of rates and the influence of sex, urbanicity, migrant
status and methodology
John McGrath*1,2, Sukanta Saha1, Joy Welham1, Ossama El Saadi1,
Clare MacCauley1 and David Chant1,2

Address: 1Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, Q4076, Australia and 2Department of
Psychiatry, University of Queensland, St Lucia, Q4072, Australia
Email: John McGrath* - john_mcgrath@qcsr.uq.edu.au; Sukanta Saha - sukanta_saha@qcsr.uq.edu.au;
Joy Welham - joy_welham@qcsr.uq.edu.au; Ossama El Saadi - ossama_elsaadi@qcsr.uq.edu.au;
Clare MacCauley - clare_maccauley@qcsr.uq.edu.au; David Chant - david_chant@qcsr.uq.edu.au
* Corresponding author

Published: 28 April 2004 Received: 02 September 2003

Accepted: 28 April 2004
BMC Medicine 2004, 2:13
This article is available from: http://www.biomedcentral.com/1741-7015/2/13
© 2004 McGrath et al; licensee BioMed Central Ltd. This is an Open Access article: verbatim copying and redistribution of this article are permitted in all
media for any purpose, provided this notice is preserved along with the article's original URL.

Abstract
Background: Understanding variations in the incidence of schizophrenia is a crucial step in unravelling the
aetiology of this group of disorders. The aims of this review are to systematically identify studies related to the
incidence of schizophrenia, to describe the key features of these studies, and to explore the distribution of rates
derived from these studies.
Methods: Studies with original data related to the incidence of schizophrenia (published 1965–2001) were
identified via searching electronic databases, reviewing citations and writing to authors. These studies were
divided into core studies, migrant studies, cohort studies and studies based on Other Special Groups. Between-
and within-study filters were applied in order to identify discrete rates. Cumulative plots of these rates were made
and these distributions were compared when the underlying rates were sorted according to sex, urbanicity,
migrant status and various methodological features.
Results: We identified 100 core studies, 24 migrant studies, 23 cohort studies and 14 studies based on Other
Special Groups. These studies, which were drawn from 33 countries, generated a total of 1,458 rates. Based on
discrete core data for persons (55 studies and 170 rates), the distribution of rates was asymmetric and had a
median value (10%–90% quantile) of 15.2 (7.7–43.0) per 100,000. The distribution of rates was significantly higher
in males compared to females; the male/female rate ratio median (10%–90% quantile) was 1.40 (0.9–2.4). Those
studies conducted in urban versus mixed urban-rural catchment areas generated significantly higher rate
distributions. The distribution of rates in migrants was significantly higher compared to native-born; the migrant/
native-born rate ratio median (10%–90% quantile) was 4.6 (1.0–12.8). Apart from the finding that older studies
reported higher rates, other study features were not associated with significantly different rate distributions (e.g.
overall quality, methods related to case finding, diagnostic confirmation and criteria, the use of age-standardization
and age range).
Conclusions: There is a wealth of data available on the incidence of schizophrenia. The width and skew of the
rate distribution, and the significant impact of sex, urbanicity and migrant status on these distributions, indicate
substantial variations in the incidence of schizophrenia.

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Background
Why is a systematic review needed?
Gradients in the incidence of a disorder across time and
across place can provide powerful clues to help unravel
the aetiology of that disorder [1]. Numerous studies over
the last few decades have presented original data on the
incidence of schizophrenia, and several scholarly reviews
have collated these studies [2-5]. Until recently, reviews of
observational and experimental studies have used stand-
ard narrative approaches. However, over the last decade
there has been a growing appreciation that reviews should
be based on data that are as complete and as free of bias
as possible [6]. Data from treatment or intervention stud-
ies have often been pooled using meta-analysis [7]. Even
without pooling of data, the orderly sorting of data with
meta-analytic techniques can provide useful insights into
the structure of the relevant literature [8]. The need for
such an exercise with respect to the incidence of schizo-
phrenia was recognized by Jablensky [5] in an influential
review: "Ideally, a meta-analysis involving a standardized
recalculation of the rates from many previous studies
should generate a distribution allowing one to estimate
with some probability the extent to which populations
differ" (p 219). We believe that a systematic review of the
incidence of schizophrenia will help inform the research
community, and thus contribute to the generation of
hypotheses about the etiology of schizophrenia.
Ways to measure the incidence of schizophrenia
The incidence of a disease is a measure of the number of
new cases that occur in a population over a given period
of observation (see Additional File 1 for a glossary of def-
initions of terms and abbreviations used in this review).
Traditional incidence studies (henceforth referred to as
core studies) establish a rate based on the general popula-
tion residing within a defined catchment area. National or
health district catchment areas have often provided con-
venient boundaries regarding access to services and mini-
mal out-of-area leakage. However, it should be noted that
the boundaries chosen for incidence studies may not be
optimal for the detection of variations of the disorder
within or between various populations. In other words,
there is no reason to believe that the genetic or environ-
mental factors associated with the incidence of schizo-
phrenia respect political or health-district boundaries.
Nor should we expect that these risk factors are uniformly
distributed within such boundaries.
Apart from general population-based studies, there are
other studies that provide insights into the incidence of
schizophrenia in subgroups of the general population.
One type of population subgroup is the cohort defined by
the year of birth. Subjects born in a particular time period
(for example, 1966), can be identified and then tracked
prospectively in order to identify the number of individu-
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als who subsequently develop schizophrenia by a certain
age. Cohorts can also be defined retrospectively. For
example, a researcher may use a population register to
identify all adults within a defined catchment area (for
example, national boundary) who were born within a cer-
tain time period. Cross linking the population register
with a mental health register can be used to identify
cohort members who received treatment for schizophre-
nia up until a certain date. Cohort studies can provide
information of the incidence of a disorder up to various
ages within that cohort.
In addition to cohorts, the incidence of schizophrenia can
also be examined in subgroups of the population defined
by other criteria. Reporting the incidence of schizophrenia
in subgroups of the population is standard practice in core
incidence studies. For example, most studies report inci-
dence rates for persons (that is, the general population)
and then males and females separately (that is, subgroups
of the population). In recent years there has been interest
in subgroups defined by migrant status and risk of schiz-
ophrenia. Some studies report incidence rates in certain
subgroups only (for example, twins, the deaf, those who
belong to a certain religion or ethnic group, those aged 65
years or older). We have labelled these studies as Other
Special Groups. Rates from migrant and Other Special
Groups will be assessed separately in this review.
Studies from countries with comprehensive cross-linked
national registers have been able to present incidence data
based on person-years. Rather than present the number of
new cases per 100,000 per year, these studies present the
number of new cases that have accumulated over several
years against a person-years denominator. This denomi-
nator takes into account the size of the underlying popu-
lation sample, its age structure and mortality over the
duration of observation. These studies will be considered
separately to the core studies.
Finally, a systematic review such as this has to decide
where to 'draw the line' between studies primarily
designed to assess the incidence of schizophrenia, versus
those studies primarily designed to compare incidence
data with respect to the presence or absence of a candidate
risk factor. For example, a study may compare the inci-
dence of schizophrenia in a cohort exposed to different
levels of urbanicity at birth, season of birth and family his-
tory [9]. Data related to the incidence of schizophrenia
can often be found in studies exploring candidate non-
genetic risk factors such as prenatal famine [10], influenza
[11] and obstetric complications [12]. Such studies can
provide additional data related to the incidence of schizo-
phrenia but will not be covered in this review.
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Key research questions related to the incidence of
schizophrenia
What is the range of incidence rates?
The most influential study of the incidence of schizophre-
nia has been the WHO 10 Nation study [13]. This land-
mark study, which employed uniform methodology
across sites, provided incidence data from eight sites
(seven nations). When narrow criteria for schizophrenia
were used (CATEGO S+), the incidence ranged from seven
to 14 per 100,000 (Aarhus, Denmark to Nottingham, UK,
respectively), while the range for ICD9 schizophrenia was
16 to 42 per 100,000 (Honolulu, Hawaii to the urban
Chandigarh, India, respectively). Both definitions found
at least a two-fold difference between the highest and low-
est sites, and this difference for the broad (but not narrow)
definition was statistically significant. Regardless of
whether the incidence rates for the eight sites were signif-
icantly different, the authors of the study drew attention
to the relatively narrow range of incidence rates identified
in this study [13].
The results of the WHO 10 Nation study have often been
misinterpreted as providing strong proof that the inci-
dence of schizophrenia does not vary between sites. For
example, Crow has stated, "The evidence points to the sin-
gular conclusion that, contrary to almost any other com-
mon condition, the incidence of schizophrenia is
independent of the environment and a characteristic of
human populations." (p119) [14]. In a recent narrative
review, Jablenksy [15] restates the issue more concisely:
"The general conclusion is that according to the great
majority of studies, the prevalence and incidence rates of
schizophrenia are similar across populations. However, a
small number of populations have been identified that
clearly deviate from this central tendency. The magnitude
of these deviations is modest compared with the differ-
ence observed across populations with regard to other
multifactorial diseases such as diabetes, ischaemic heart
disease or cancer, where 10- to 30-fold differences in prev-
alence across populations are not uncommon." (p212).
This systematic review will examine the central tendency
and spread of data related to the incidence of
schizophrenia.
Sex differences
Several reviews have drawn attention to sex differences in
key epidemiological features of schizophrenia [16-18].
Recently, a systematic review and meta-analysis reported a
higher incidence of schizophrenia in men versus women
[17]. This systematic review will compare the distribu-
tions of rates for males versus females, and examine the
central tendency and distribution of the male to female
risk ratio.
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Urban versus rural place of residence
There is evidence that urban settings are associated with
higher rates of schizophrenia. While there are post-onset
factors such as selective migration that may contribute to
a higher prevalence of schizophrenia in cities, it is not
clear if urban living is associated with a higher risk of
developing schizophrenia. Building on the classic studies
of Faris and Dunham [19], several recent studies have
reported that being born in an urban versus rural region
was associated with an increased risk of developing schiz-
ophrenia [9,20-23]. In addition, there is evidence from a
Danish study that the number of years spent in an urban
area during childhood increased the risk of developing
schizophrenia [24]. However, because of the general
urbanization of most nations over recent decades, it is dif-
ficult to disentangle the critical window of exposure for
urbanicity [25]. A study from the Netherlands [26] looked
at urbanicity of residence around the time of first admis-
sion as well as urbanicity at time of birth. This study
reported that for those born in rural regions, urban resi-
dence around time of onset was not associated with an
increased risk of schizophrenia. However, urban birth
with or without urban place of residence around the onset
of illness was associated with an increased risk. This sys-
tematic review will separate out incidence studies from
urban, rural and mixed urban/rural setting and compare
the distributions of these rates.
Migrant status
Since the pioneering studies by Ödegård in 1932 [27], the
association between migrant status and increased risk of
schizophrenia has stimulated a great deal of research and
a wealth of creative explanatory hypotheses [28]. More
recently the issue has been put back on the agenda by
research from the United Kingdom showing higher rates
in both Afro-Caribbean migrants [29] and other migrant
groups [30]. While studies from the Netherlands [31],
Denmark [32] and Sweden [33] have supported an
increased risk of schizophrenia in migrants, not all studies
have found this association [34,35]. This systematic
review will compare the distributions of rates for native-
born individuals versus migrant groups, and examine the
central tendency and distribution of the migrant to native-
born risk ratio.
The influence of methodology on incidence rates
Systematic reviews can explore possible sources of hetero-
geneity in data sets by sorting the data according to vari-
ous rules and comparing the resulting distributions.
Design features clearly need to be taken into account
when comparing rates derived from different types of inci-
dence studies.
When comparing rates derived from different catchment
areas, it is important to note the population age structure
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within each site. The age of onset of schizophrenia is not
randomly dispersed across the lifespan (peak onset in the
second and third decades of life), thus sites with a younger
population will yield higher incidence rates. In order to
deal with this issue, some studies use techniques to adjust
the raw incidence rate against a standard or reference pop-
ulation age structure, that is, age standardization. This
provides a more valid way to compare the incidence of a
disorder in two or more populations with different age
distributions.
Apart from corrections related to age standardization,
completeness of case identification is a critical feature in
incidence studies. Thus one would predict that studies
that cover a wider spectrum of potential recruitment sites
(for example, inpatient and outpatient settings, general
practitioners, other health care providers) would be able
to identify more new cases. Method of diagnostic confir-
mation (for example, face-to-face interview versus chart
diagnosis), diagnostic criteria (CATEGO S+ versus ICD9),
age-range (all ages versus 15 to 54 years) can also influ-
ence the rate of schizophrenia [13].
In the field of systematic reviews, scores are often allo-
cated to reflect desirable features related to the validity of
the study [36]. In the field of descriptive epidemiology,
the use of quality scores to rank order studies is relatively
untested [37-39]. There are several features of Quality
Scores that need to be kept in mind. The criteria used need
to be easily operationalized and reliable, thus they tend to
involve simple, categorical judgments (criteria met versus
not met). Unfortunately, it has been shown that impor-
tant items such as "Is the sample size adequate?" cannot
be reliably operationalized [38]. It is self-evident that the
ability to judge the quality of the study is contingent on
the quality of the reporting of that study.
Finally, some commentators have noted that more recent
studies have reported lower rates, suggesting that the inci-
dence of schizophrenia is changing over time [40-42]. We
explored this issue in the data set, and predicted that more
recent studies would report rates that were lower com-
pared to older studies.
Aims and hypotheses of this study
As part of a wider systematic review of the incidence and
prevalence of schizophrenia, here we present those data
and analyses related to the incidence of schizophrenia. We
will present the methods of the analyses and the key char-
acteristics of the included studies (divided into core stud-
ies, cohort and Other Special Groups). We will describe
the distribution of rates and then sort these rates in order
to examine several main hypotheses. Based the literature
described above, we predict that: (a) males will have
higher rates compared to females; (b) studies based on
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urban sites will have higher incidence compared to stud-
ies from rural or mixed urban-rural sites; and (c) migrant
groups will have higher rates compared to native born. In
addition, the influence of selected methodological fea-
tures (quality score, year of study, scope of coverage,
method of case finding, diagnostic criteria, age range, the
use of age-standardization) will also be explored.
The over-riding aim of this research is to ensure that the
highest quality evidence informs the scientific discourse
about the incidence of schizophrenia. Therefore, we have
made the data used in this systematic review freely availa-
ble to the research community. The data used in the anal-
yses are available in both Access and Excel files attached to
the electronic version of this paper.
Methods
Identification of studies
As part of the wider study of the incidence and prevalence
of schizophrenia, a broad search string ((schizo* OR
psych*) AND (incidence OR prevalence)) was used in
MEDLINE, PsychINFO, EMBASE and LILACS. Title and
abstracts, if available, were reviewed in order to exclude
irrelevant studies. Potentially relevant papers were
accessed in order to review the full text. The references
cited by each potentially relevant paper, as well as the cita-
tions in major review papers and book chapters, were
scrutinized in order to locate additional potentially rele-
vant papers. Posters were presented at two international
schizophrenia conferences [43,44] in order to encourage
researchers to contribute studies, especially studies from
the 'grey literature' (for example, conference reports, the-
ses, government reports, unpublished studies). Subse-
quently, letters or emails were sent to the senior authors
of papers that met the inclusion criteria. In these letters,
which included the most-recent list of included studies,
authors were asked to inform us of missing papers and
unpublished data.
Included studies
We included studies first published between January 1965
and December 2001 that reported primary data on the
incidence of schizophrenia (according to any diagnostic
criteria), drawn from either a general population sample
or a subgroup of the population. Where multiple publica-
tions presented identical data, the most informative ver-
sion of the study was included and the other related
papers were excluded (full list available on request). At the
time of submission, papers that had not yet been located
were allocated to the 'Awaiting Assessment' category.
Data extraction
Once a study was included, data were extracted related to
study-level variables (for example, authors, year of publi-
cation, site, urban/rural status, recruitment duration and
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years covered, case finding method, method of confirm-
ing diagnosis, diagnostic criteria), and rate-level variables
(for example, rates for persons, males, females, rate of dif-
ferent diagnostic criteria, different age-specific rates). Full
rate-level data for these variables can be found in the
Additional File 6 (Excel format) and Additional File 7
(Zipped Access format). Two or more of the authors
checked all data used in the analysis. When disagreements
arose, these were resolved by consensus. If required, we
contacted the authors for clarification of issues.
Studies were given quality points for certain features (for
example, greater coverage, use of diagnostic criteria, qual-
ity of diagnostic method, thoroughness of reporting, etc).
Details of the quality score used in this review are pro-
vided in Additional File 2.
It is important to remain mindful that one study may gen-
erate many items of information on the incidence of
schizophrenia. Some of the rates are discrete (non-over-
lapping) such as those related to sex, epoch (for example,
1976 versus 1977) or location (Chandigarh urban versus
Chandigrah rural).
Some of the rates overlap, such as those for age range (all
age versus age-specific age bands), diagnostic criteria (ICD
criteria and DSM criteria), and epoch (1976 alone versus
average for 1975–1980).
Sorting the rates by the application of sequential filters
In order to deal with the range of study level and rate level
variables identified by the systematic review, the data were
categorized and then filtered by a series of criteria. For
example, the first filter parsed rates from the included
studies into four categories: (a) core studies, (b) migrant
studies, (c) cohort studies, and (d) Other Special Groups.
Next, a study-level filter was applied in order to isolate dis-
crete data from multiple studies that overlapped in both
time and place. This was required in order to eliminate
several papers counting the same subjects more than once.
We selected one paper from overlapping papers according
to rules that prioritized the most 'informative' paper. Pri-
ority was given to studies with: (a) larger catchment areas,
(b) larger general populations, and (c) longer duration of
recruitment.
For studies that presented rate level data for the same indi-
viduals according to various criteria, a third filter was
designed in order to select one representative rate for
inclusion in the cumulative distribution. Once again, we
selected one rate according to rules that prioritized the
most 'informative' rates. Priority was given to rates that
covered (a) the widest age range, (b) crude incidence rates
rather than age-standardized rates (because more papers
presented only raw rates and those that did present age-
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standardized rates rarely provided information about the
method of standardization), (c) diagnostic criteria that
were more prevalent in the included studies (for example,
as ICD criteria were most often used, for studies that pre-
sented rates according to ICD and any other criteria, we
chose the ICD rate; for studies that presented multiple
CATEGO diagnoses, we selected the broadest SPO+ clini-
cal). Details of the study-level and rate-level selections are
provided in the Additional File 6 and 7. These rules were
applied by two of more of the authors, and when disagree-
ments arose, the decision was made by consensus.
Presentation and analyses of the data
For practical purposes, it is not possible to show every
numerator, denominator and rate for the studies in
printed tables, thus we will provide the total number of
rates per study, and, where available, show the largest rate
level numerator and its associated denominator for per-
sons (or, if this is not available, the range for males and
females).
The distribution of incidence rates is presented in cumu-
lative plots. The distribution of the data is shown in rank
order for incidence rate (lowest to highest ranks) with the
cumulative percent of rates shown on the vertical axis. The
plots show the 50% (median), and 25% and 75% quan-
tiles (within which lies the inter-quartile range). We wish
to draw the reader's attention to several features of these
graphs. Firstly, the central, near-linear segment of the
cumulative distributions may extend beyond the inter-
quartile range (for example, from the 10%–80% quan-
tiles), thus shape features (where the tails start, the range
of the linear central segment) can be more informative
than traditional inter-quartile ranges. Secondly, steeper
segments of the cumulative plots are underpinned by rates
that have a narrow distribution, while flatter (that is, more
horizontal) segments of the distribution are underpinned
by rates that are relatively more dispersed. Finally, some
distributions are derived from more data than others.
Regardless of slope, that is, steep or flat, if many rates
underpin segments of the distributions, these segments
warrant closer investigation, especially in analytic
contexts, compared to sparsely plotted segments of the
distribution.
The data will be presented for persons, as well as for males
and females separately. The main analyses will be based
on discrete (non-overlapping) core rates. Readers familiar
with meta-analyses may expect to see figures displaying
confidence intervals and pooled data, as well as read
information related to formal tests exploring heterogene-
ity in the data. For several reasons, the data in this review
do not lend themselves to these types of analyses. Among
the 68 discrete core studies (see below), only four [31,45-
47] supply confidence limits, and no other measures of
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spread (for example, standard errors) are reported. We
were able to derive the standard error of the crude annual
incidence rate from studies that reported the correspond-
ing numerator, denominator, and duration of recruit-
ment. Based on these calculations, we were only able to
generate standard errors for 117 of the 373 (31.4%) rates,
drawn from only 45 (45.0%) of the discrete core studies.
Faced with such a restricted pool of standard errors, the
ability to assess the heterogeneity of rates in a manner
generalizable across all core studies is compromised. In
addition, the issues that underlie the decision to combine
data from randomized controlled trials or risk-factor epi-
demiological studies are of less relevance to incidence
rates. For example, should incidence studies from very
large populations (for example, one study from former
East Pakistan has a population denominator of 51 mil-
lion) [48] be allowed to exert several hundred times more
influence on analyses than 'smaller' studies?
However, merely presenting the graphical displays of rate
distributions does not allow a formal test of the hypothe-
ses outlined above. No matter how appealing the descrip-
tive approach, we are inevitably drawn into inferential
statistics, and are forced to choose the least biased and
most transparent method to compare the distributions.
The analysis of the data in this systematic review poses
two particular issues. Firstly, rates drawn from the same
study tend to be more alike than those from different
studies. Thus any comparison between distributions
needs to control for the fact that one study may generate
more than one rate (that is, the within-study variance).
Secondly, because the distribution of the rates was often
positively-skewed, the data required log-transformation.
In order to aid interpretation of the distribution of the
rates, Tables 123 present three measures of central ten-
dency: the median, the arithmetic mean and the harmonic
mean (which is a better indicator of the central tendency
of the log-transformed data). As a consequence of these
two issues, the statistical comparisons between distribu-
tions may not always concur with the visual interpretation
of the raw distributions.

Table 1: Characteristics (quantiles and moments) of incidence rates per 100,000, for rates for persons, males and females, and male to
female rate ratio

ns (nr) 10% 25% Median 75% 90% Mean s mh

Persons 55 (170) 7.7 10.2 15.2 22.0 43.0 23.7 30.3 15.9
Males 31 (100) 6.6 11.4 15.0 24.8 34.1 21.8 27.4 16.2
Females 31 (100) 3.0 6.3 10.0 21.8 30.2 21.3 45.1 11.3
Male to 31 (100) 0.9 1.1 1.4 1.8 2.4 1.5 0.6 1.4
female rate
ratio

ns, number of studies; nr, number of rates; s, standard deviation; mh, harmonic mean of the rates.

Table 2: Characteristics (quantiles and moments) of incidence rates per 100,000 by sex and urbanicity

ns (nr) 10% 5% Median 75% 90% Mean s mh

Persons
Urban 23 (67) 7.5 11.2 19.0 39.9 67.0 30.8 38.5 20.4
Rural 5 (7) 0.0 11.0 20.0 23.0 222.6 45.4 78.6 27.9
Mixed 29 (96) 7.9 10.0 13.3 19.4 26.0 15.3 8.6 12.9
Males
Urban 10 (20) 10.7 13.5 24.6 45.4 64.5 39.6 57.8 24.8
Rural 2 (2) 19.0 19.0 69.7 120.3 120.3 69.7 71.7 47.8
Mixed 20 (80) 6.5 9.7 13.9 22.8 27.4 16.1 7.9 14.2
Females
Urban 10 (20) 7.5 11.5 22.7 49.3 74.5 43.3 67.4 23.4
Rural 2 (2) 23.0 23.0 174.9 326.8 326.8 174.9 214.8 86.7
Mixed 20 (79) 3.0 4.6 8.0 20.0 24.0 11.6 8.1 8.9

ns, number of studies, nr, number of rates, s, standard deviation, mh, harmonic mean of the rates.

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Table 3: Characteristics (quantiles and moments) of incidence rates per 100,000, by Migrant Status, and Migrant to Native-born rate
ratio by sex

ns (nr) 10% 25% Median 75% 90% Mean s mh

Persons
Migrant 17 (48) 13.5 40.0 60.0 109.5 615.4 140.9 208.2 77.3
Native 15 (20) 6.9 8.4 16.9 32.5 111.0 35.8 45.1 19.9
Males
Migrant 10 (51) 10.2 18.0 39.0 131.0 161.0 72.5 66.1 46.6
Native 10 (14) 9.0 18.6 22.5 27.0 41.9 26.4 21.0 20.1
Females
Migrant 10 (51) 6.0 8.0 22.0 51.0 66.9 41.5 61.5 24.4
Native 10 (14) 4.9 9.0 15.5 19.1 30.0 20.3 23.8 13.4
Migrant to
Native born
rate ratio
Persons 15 (43) 1.0 2.7 4.6 6.8 12.8 7.4 12.0 4.7
Males 10 (47) 0.8 1.2 2.3 4.8 6.5 3.1 2.2 2.5
Females 10 (47) 0.4 0.9 1.7 3.1 3.9 2.5 2.9 1.8

ns, number of studies, nr, number of rates, s, standard deviation, mh, harmonic mean of the rates.

Results [40,180,181] and one study contributed to Other Special

The electronic search identified 834 papers, while manual
reference checking identified an additional 249 refer-
ences. We received responses from 52 authors (see
Acknowledgements for full list), who provided an addi-
tional 41 references (Figure 1). At the level of potentially
relevant papers, 74% were identified from electronic
sources. We identified 98 studies in Languages Other
Than English (LOTE). After translation, 10 were included
in the study. The subsequent culling and final distribution
of the papers is shown in Figure 1.
The rates were based on an estimated 176,056 potentially
overlapping incident cases. Key details of the included
studies are shown in Tables S1–S4, which can be found in
Additional File 4. The systematic review identified 100
core studies [13,31,33,40,41,45-61,63,65-127,148,180-
192]. The 158 included studies were drawn from 32 coun-
tries. One study [13] provided rates for seven countries,
and another provided rates for two countries [74]. Details
of these studies are shown in Table S1 in Additional File 4.
There were 24 migrant studies [31,33,35,121,128-147],
23 cohort studies [9,10,21,23,42,149-165,193] and 14
studies that reported the incidence of schizophrenia in
Other Special Groups [166-179]. Key features of these
studies can be found in Tables S2, S3 and S4 in Additional
File 4.
The review identified four studies that presented standard-
ized incidence rates (rate ratio of specific group versus a
reference group) [40,174,180,181], however rates from
several of these studies also contributed to the core rates
Groups [174]. Of the included studies, 13 included at
least one rate with person years as the denominator
[9,21,31,42,74,93,121,130,133,152,163,167,174]. Per-
son-year incidence rates have been used in descriptive and
model-based analyses alongside crude annual rates. While
this has the potential to distort results (an annualised per-
son-year rate will almost never agree with a notionally
corresponding crude annual rate), it is hoped that the dis-
tortion is minimal.
Of the 1,457 rates in the included studies, 501 (34.4%),
from 42 studies, employed age-standardization:
[13,31,35,45,46,50,56,68,74,76,80,88,91,102,107,109,1
10,115,116,118,124,127,128,130,133,135-
138,141,142,144-150,168,181,187,188]. As with person-
year incidence rates, age-standardized rates have been
used alongside crude rates. The impact of age-standardiza-
tion versus raw rates will be addressed below.
Core studies
Out of 100 core studies, 39 studies report rates only for
persons [33,40,45,47,48,55-
57,59,61,73,75,79,86,87,116,91,93-96,99,103,104,107-
109,112-114,118,120-122,124-127,183,192], 16 report
rates only for males and females
[41,63,68,74,82,102,110,111,116,117,119,123,187-
190], and 45 studies report rates for persons, males, and
females [13,31,46,49-54,58,60,65-67,69-72,76-
78,80,81,83-85,88-
90,92,97,98,100,101,105,106,115,148,180-182,184-
186,191].

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BMC Medicine 2004, 2 http://www.biomedcentral.com/1741-7015/2/13

Studies from electronic

databases (834)

Additional studies from

bibliography (249)

Additional studies after

contact with authors (41)

Total potential studies (1124)

Not incidence/prevalence of schizophrenia

(235)

Review/commentary (145)

Waiting assessment/unobtainable (37)

First published before 1965 (4)

Potential Incidence & Prevalence studies = 703

Not population-based (201)

Prevalence Insufficient data (69)

(248)
Follow up/other studies (23)

Incidence/Prevalence studies (371) LOTE (98)

Incidence & Incidence (137)

Prevalence (23)

Included incidence rates (158) LOTE incidence

(10)

Other Special Groups (14) Cohorts (23)

Core studies (100) Migrant studies (24)

Figure
Flow diagram
1 (selection strategy) of included studies
Flow diagram (selection strategy) of included studies. LOTE, Languages other than English.

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BMC Medicine 2004, 2
The studies provided between one to 96 rates per study;
the WHO 10 nation study was the most informative study
[13]. Of the 509 rates derived from the core studies, 79%
relied on chart or register-based diagnosis, a further 7%
relied on the application of diagnostic criteria applied to
written case note material, and only 11% relied on face-
to-face interview (the remaining rates used other methods
or this information was not specified). The most com-
monly used diagnostic criterion for the rates in the core
studies was one of the ICD classifications (60%), while
6% used a CATEGO-derived classification, 4% used DSM,
and 4% used RDC. The remaining 28% used two criteria
serially (for example, ICD9 chart diagnosis followed by
DSM-III-R diagnoses) or did not specify the diagnostic
criteria.
Discrete-core studies
Out of 100 core studies 68 studies provided at least one
discrete rate [13,31,33,41,45-61,65,67,69-80,82-
86,88,91-104,106,107,111,112,114,116,121,123-
126,188,189]. The remaining 32 studies included rates
that overlapped, by year and place, completely or partially
with discrete core rates. The 68 discrete-core studies were
drawn from 27 countries.
Thirty seven discrete-core studies report rates only for per-
sons [31,33,45-49,55-
57,59,61,65,71,73,75,76,78,79,85,86,88,91,93-
96,99,103,104,107,112,114,121,124-126,180,190], 13
report rates only for males and females
[41,50,52,53,67,74,82,102,111,116,123,188,189], and
18 studies report rates for persons, males, and females
[13,51,54,58,60,69,70,72,77,80,83,84,92,97,98,100,101
,106].
Of the 68 discrete-core studies, 41 (60.3%) relied on chart
or register-based diagnosis, a further nine (13.2%) relied
on the application of diagnostic criteria applied to written
case note material, and 15 (22.1%) relied on face-to-face
interview (the remaining core studies used other methods
or this information was not specified). In terms of the 373
associated rates, 276 (74.0%) relied on chart or register-
based diagnosis, 28 (7.5%) relied on the application of
diagnostic criteria applied to written case note material,
and 45 (12.1%) relied on face-to-face interview.
The most commonly used diagnostic criterion for the 68
discrete-core studies was one of the ICD classifications
(51.5%), while 5.9% used a CATEGO-derived classifica-
tion, 11.8% used DSM, and 2.9% used RDC. The remain-
ing 27.9% either used another criterion, or used multiple
criteria serially (for example, ICD 9 chart diagnosis fol-
lowed by DSM IIIR diagnoses), or did not specify the diag-
nostic criteria.
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Of the 373 discrete-core rates, 25.2% (n = 94), coming
from 13 studies, were age-standardized
[31,45,46,50,56,74,80,91,102,107,116,124,188].
Figure 2 shows the distribution of rates for persons, males
and females, based on discrete-core data. In order to aid
visual representation, the figure has been truncated at 100
per 100,000, however the quantiles and moments that
characterize the distribution are based on all rates. Table 1
shows the quantiles and moments of these distributions.
For persons, based on 170 rates, the median incidence
rate was 15.2 per 100,000, and the 10% and 90% quan-
tiles ranged from 7.7 to 43.0 per 100,000 (a 5.6-fold
difference).
Sex ratio
Unexpectedly, we noted that studies that only report inci-
dence rates for persons appeared to report higher rates
than studies that reported rates for males and females only
or studies reporting males, females and persons (for fig-
ures and tables related to these analyses, see Additional
File 3 and 5 respectively). This feature needs to be kept in
mind in analyses that split by persons, males and females.
Figure 3 shows the distribution of the rate ratio for males
versus females. These ratios are matched, and derived
from within-study male to female ratios. Values greater
than one indicate a higher incidence of schizophrenia in
males compared to females. The rate ratio curve is nor-
mally distributed. While there were nine studies with rate
ratios less than one [13,41,51,60,69,70,72,83,106,111],
over 84% of rates lie above one, with a median value
(10% to 90% quantiles) of 1.40 (0.9, 2.4). In a random-
effects model for the logarithm of the rates, the sex-differ-
ence is significant (F1,30 = 76.8, p < 0.001).
Urbanicity
We identified 21 discrete-core studies with rates from
urban sites [31,33,54,61,69-
71,75,78,80,84,91,93,97,98,100,103,106,121,124,125],
three studies from rural sites [57,59,60], and 42 studies
with mixed urban-rural catchment areas [41,45-
49],230,[50-53,55,56,58,65,67,72-
74,76,77,79,82,83,85,86,88,92,94-
96,99,101,102,104,107,111,112,114,116,123,188,189].
Two further studies provide rates for both urban and rural
categories [13,126].
Table 2 and Figure 4 summarize the characteristics of the
rates by sex and urbanicity. Because of the within-study
configuration of both sex and urbanicity, and the paucity
of studies on the rural sector, significance tests can only be
constructed for differences between the urban and mixed
categorizations.
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BMC Medicine 2004, 2
Figure 2 plots of the incidence rates per 100,000, by sex (plot truncated at 100)
Cumulative
Cumulative plots of the incidence rates per 100,000, by sex (plot truncated at 100).
The difference in harmonic means is significant for per-
sons (F1,50 = 6.06, p = 0.02); non-significant for males
(F1,28 = 2.7, p = 0.11); and of borderline significance for
females (F1,28 = 4.2, p = 0.05).
Migrant status
We identified 24 migrant studies from five countries
[128], Germany (n = 1) [35], Sweden (n = 1) [33], The
Netherlands (n = 3) [31,129,130], and the United King-
dom (n = 18) [121,131-147]. One study [144] was
excluded from the analysis because of overlapping by time
and place. Table S2 (see Additional File 4) presents a list
of migrant studies with key descriptive variables,
incidence rates and within-study rate ratios. The table
highlights the variable definitions of first and second gen-
eration migrants used in these studies – an issue that
could be more closely scrutinized in the future.
Overall migrant groups displayed elevated incidence of
schizophrenia compared to their native-born populations
(Table 3 and Figure 5). Note that there are more rates for
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migrant groups than for native-born populations, reflect-
ing the fact that many studies reported rates for several dif-
ferent migrant groups. The migrant to native-born rate
ratio median (10% to 90% quantiles) was 4.6 (1.0 to
12.8) (Table 3 and Figure 6). In particular, the migrant
groups had higher rates for persons in the upper half of
the distribution. The difference in harmonic means
between migrants versus native-born is significant for per-
sons (F1,13 = 51.8, p < 0.001); for males (F1,8 = 27.1, p <
0.001); and for females (F1,8 = 10.4, p = 0.01).
Methodological features
Additional figures (Figures S1–S8) and detailed tables
(Tables S6–S16) related to the following section can be
found in the Additional File 3 and 5 respectively.
Eight of the 68 studies show variation in quality score
within studies, but always by two points at most on the
scale. Thus we used the average quality score per study as
our measure of a study's quality. When divided into ter-
ciles for quality score, the distribution of rates did not dif-
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BMC Medicine 2004, 2
Figure
The cumulative
3 percentage of the rate ratio of the incidence of schizophrenia in males versus females
The cumulative percentage of the rate ratio of the incidence of schizophrenia in males versus females.
fer significantly (F2,65 = 0.34, p = 0.72). Concerning
methods of case identification, only eight studies used
community-based surveys in order to ascertain cases
[13,45,46,55,57,78,88,127]. When the rates were
arranged by method of case identification, the rate distri-
butions did not differ significantly (F3,64 = 0.14, p = 0.93).
Fifteen of the 68 discrete-core studies relied on face-to-
face interviews in order to confirm the diagnosis
[13,31,45,56,57,59,65,73,76,78,82,88,101,104,125].
When the rates were arranged by method of diagnostic
confirmation, they did not differ significantly (F3,62 =
0.17, p = 0.92). Curiously, the studies that went to the
effort of using face-to-face diagnostic interview tended to
yield similar incidence rates as studies using chart/case
records (median 14.0). The studies with systematic review
of case notes produced numerically higher incidence rates
(median 21.0).
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Twelve studies reported reliability data on their diagnostic
techniques [13,33,45,54,65,71,78,83,96,102,121,124],
and one study reported details of a 'leakage study' in order
to identify potential missed cases [78]. Eight studies
[46,53,54,61,72,74,101,117] provided more than one
method of diagnostic assessment, however in this review
we had to choose only one method in accordance with the
rules outlined above. When the rates were arranged by
diagnostic criteria, there were no significant differences
amongst the distributions (F4,63 = 0.04, p = 0.99).
Surprisingly, when the rates were divided into those that
were age-standardized versus raw rates, these distributions
did not differ significantly (F1,48 = 0.24, p = 0.63), nor did
age-range impact significantly on the rate distributions
(F2,36 = 0.80, p = 0.42). Only one of the methodology var-
iables revealed a significant difference – year of first
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BMC Medicine 2004, 2
Figure 4 plots of the incidence rates per 100,000, and urbanicity of site (plot truncated at 200)
Cumulative
Cumulative plots of the incidence rates per 100,000, and urbanicity of site (plot truncated at 200).
intake, a measure related to possible secular change. The
differences among harmonic means was significant (F2,18
= 13.3, p < 0.001), with significant differences among all
three harmonic means (in particular 1949–1975 versus
1976–1983, p < 0.001 unadjusted; 1976–1983 versus
1984–1995, p = 0.005 unadjusted).
Cohort and Other Special Group studies
We identified 23 discrete cohorts that have reported either
cumulative incidence proportion or other measures of the
occurrence of schizophrenia [9,10,21,23,42,149-
165,193]. Some of these cohorts have generated multiple
publications reporting the incidence of schizophrenia
over time. These cohorts came from nine sites: Australia
(n = 2) [149,150], Denmark (n = 3) [9,151,193], Finland
(n = 5) [42,152-155], Israel (n = 2) [156,157], Italy (n =
1) [158], Sweden (n = 2) [21,159], The Netherlands (n =
2) [10,23], USA (n = 3) [163-165], and the United King-
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dom (n = 3) [160-162]. Because of differences in the age
of the cohorts, the rates are not readily comparable; how-
ever the highest cumulative incidences have been reported
from Finland and the United States.
In addition, we identified 14 studies that reported the
incidence of schizophrenia in the following subgroups of
the population: over age 65, twins, various ethnic and/or
religious subgroups, the offspring of certain Jewish immi-
grants, students, deaf individuals, and workers in a radia-
tion contamination zone [166-179]. These studies came
from 11 countries: Denmark (n = 2) [166,167], Israel (n =
1) [168], Mauritius (n = 1) [169], New Zealand (n = 1)
[170], Norway (n = 1) [171], Romania (n = 1) [172], Rus-
sian Federation (n = 1) [173], Sweden (n = 1) [174], USA
(n = 1) [179], Ukraine (n = 1) [175], and the United King-
dom (n = 3) [176-178].
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BMC Medicine 2004, 2
Figure 5 percentage of incidence of schizophrenia per 100,000 in persons by migrant status
Cumulative
Cumulative percentage of incidence of schizophrenia per 100,000 in persons by migrant status.
Key details of the Cohort and Other Special Groups can be
found in the tables included in Additional File 4.
Discussion
A total of 1,457 rates from 158 studies were identified in
this systematic review of the incidence of schizophrenia,
thus it is understandable that the reader interested in this
area may 'starve amidst plenty'. After the application of
various filters, inspection of the distribution of the rates
was informative. Most distributions were data-rich, and
many had central segments densely underpinned by data.
The distribution of rates
For persons in discrete core studies, 55 different studies
provided 170 rates. The median value for rates was 15.2
per 100,000. The distribution was positively skewed, con-
sistent with previous comments on the distribution of the
incidence of schizophrenia [5]. Excluding the top and
lower 10% of the distribution, rates ranged from 7.7 to
43.0 per 100,000. Because schizophrenia has a relatively
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low incidence rate, zero provides an absolute 'floor' for
the rate distribution. It is of interest to note that while the
lower tails of the distributions were usually data-sparse,
many of the distributions had upper tails that contained
more than 25% of the rates. Several of the distributions
had marked positive skewness. Thus, while Jablensky
commented that "a small number of populations have
been identified that clearly deviate from this central ten-
dency" [5], the data suggest that the number of studies
that 'deviate' may not be so small, and that this deviation
is predominantly for high rates, rather than low rates.
Mindful that we are dealing with a disorder with a rela-
tively low incidence rate, it is a moot point if the range is
narrower or wider than other low incidence rate disorders.
For example, Type I diabetes occurring before age 15 also
has a relatively low incidence. However, a WHO-spon-
sored systematic review of studies that used a shared defi-
nition of Type I diabetes described the range of 10 to 40
per 100,000 as "prominent worldwide variation" [194].
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BMC Medicine 2004, 2
Figure 6 percentage of rate ratio between migrants and natives in persons, males and females
Cumulative
Cumulative percentage of rate ratio between migrants and natives in persons, males and females.
So, comparable incidence ranges may be described as
"lacking in variation" by some commentators, and "mark-
edly variable" by others. Regardless of the adjectives used
to describe the distribution of rates, researchers must
strive to understand the factors that drive this variation.
Sex and schizophrenia
Based on studies identified in this systematic review, rates
were generally higher in males compared to females. The
rate distributions suggest that the magnitude of the sex
difference is relatively constant across most studies, how-
ever for studies that report a higher incidence of schizo-
phrenia (for example, greater than 32 per 100,000), the
size of the male excess may be smaller. The median male/
female rate ratio was 1.40 (inter-quartile range = 1.1 to
1.8), which is similar to a pooled risk ratio derived from
core, migrant and cohort-derived incidence data [17]. We
note that nine studies [13,41,51,60,69,70,72,83,106,111]
reported a risk ratio of less than one (that is, higher inci-
dence of schizophrenia in females versus males). We
examined the major characteristics of these studies, but
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could not identify any consistent feature that distin-
guished these studies from those with rate ratios greater
than one.
It should be noted that the studies that underpin the male
to female rate distribution have been collected over sev-
eral decades from many different nations, and have been
based on many different design features. The fact that the
distribution of the male to female rate ratio is a normal
distribution is visually striking. While it is feasible that
these studies share systematic biases that may have influ-
enced the findings (for example, excluding older age
groups), in order to 'wash out' this finding, a substantial
number of new studies reporting a male to female ratio of
less than one would need to be published.
Overall, the data indicate that the incidence of schizo-
phrenia is higher in men than in women.
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Urbanicity and the Incidence of schizophrenia
Based on the studies identified in this systematic review,
the distribution of rates derived from urban catchment
areas was higher compared with that based on mixed
urban-rural catchment areas (p = 0.02 for persons, p = 0.11
for males, and p = 0.05 for females). The small number of
rates available for rural catchment areas does not allow
the more precise urban versus rural comparison.
This finding provides support for the hypothesis that the
incidence of schizophrenia is higher in cities compared to
mixed urban/rural catchment areas. Our findings are in
keeping with recent cohort and case control studies based
on place of birth [9,23]. However, within the mixed
urban-rural studies, we were not able to infer exactly how
'rural' the mixed sites were. Indeed, we allocated studies to
the mixed category if there was any possibility that rural
sectors were included. This bias would have made any true
difference between urban versus mixed urban/rural more
difficult to detect.
Migrant status and the incidence of schizophrenia
Compared to native-born populations, rate distributions
based on migrant groups had a relatively consistent pat-
tern of higher rates compared to the distributions based
on rates for native-born individuals. This association was
also found when rates for males and females were exam-
ined separately (p < 0.001 for males, p = 0.01 for females).
Based on migrant versus native-born rate ratios, the
median rate ratio for persons was 4.6 (10% to 90% quan-
tile = 1.0, 12.8).
It is important to note that migrant studies are prone to a
range of methodological issues. These include factors
related to differential pathways to care, diagnostic inaccu-
racies (language and cultural practices may hinder accu-
rate diagnosis), potential confounding due to
socioeconomic factors and problems in determining the
numerator and denominator for the calculation of rates.
Harrison and colleagues have argued that because of these
potential biases, confidence in the link between migrant
status and schizophrenia requires consistent findings
based on different methods and from different sites [146].
While the studies analyzed in this systematic review
would share common biases, they are drawn from many
different sites, include many different migrant groups and
differ on a range of methodological features. Thus the
increased relative risk for migrants warrants added weight.
Design features of the studies
While the analyses related to the quality score and meth-
odology are interesting, we urge caution in the interpreta-
tion of these results. Researchers interested in comparing
the psychometric properties of face-to-face interviews ver-
sus chart diagnoses, or the DSM-III-R versus ICD-9
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diagnostic criteria are best directed to studies that were
primarily designed to address these issues. These method-
ological issues are important, but are more efficiently
addressed by studies based on prevalent rather than inci-
dent cases. However, mindful of the above issues, we
found that the distributions of rates did not significantly
differ when categorized by (a) quality of the study, (b) dif-
ferent methods of diagnostic confirmation, (c) different
diagnostic criteria, (d) the presence or absence of age-
standardization, and (e) different age ranges. The distribu-
tions of rates seem relatively impervious to these design
features. However, we found that rates from more recent
studies generated distributions that encompassed lower
rates compared to those distributions from older studies.
Cohort and Other Special Groups
In recent years several studies have reported the incidence
of schizophrenia in well-described birth cohorts
[161,163-165,195]. While the incidence rates from these
studies are not readily comparable to core incidence stud-
ies, the cohort studies are making important contribu-
tions to risk factor research [196]. It is of interest to note
that several of the authors of cohort studies have drawn
attention to the relatively high cumulative incidence
proportions being found in their studies
[42,154,163,164]. For example, the Finish birth cohort at
age 31 estimated the cumulative incidence of DSM-III-R
schizophrenia between 0.73% and 1.08% [195].
The Other Special Group studies share few, if any, fea-
tures. Perhaps the common feature was that the authors
felt that the incidence of schizophrenia may have differen-
tiated the particular groups under observation from the
general population. Interestingly, several of these studies
suggest that certain minority ethnic/cultural groups may
have an elevated incidence of schizophrenia [168-
170,179], which may complement the findings from
migrant studies.
Caveats
Systematic reviews are secondary research ('research on
research'). The object of scrutiny is not the incidence of
schizophrenia per se, but the literature on this topic. As
such, this type of research cannot be used to 'prove' a
hypothesis about the underlying category of observation.
However, the compiled data can encourage the generation
of new hypotheses that can then be tested prospectively,
with new data. In particular, systematic reviews can draw
attention to factors that may underlie heterogeneity of the
data.
Despite all of our efforts to ensure a complete dataset,
reviews such as this are bound to miss studies, and/or to
have data entry errors. We encourage readers to inform us
of missing studies or errors in the data. Updated lists of
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BMC Medicine 2004, 2
relevant studies and raw data will be available from the
authors. In the absence of clear guidelines, many of the
rules we used to filter studies and extract data were ad hoc.
In the future, researchers may wish to re-analyze the data
set using different criteria, and explore sensitivity analyses
related to these choices.
It is clear from the broad range of studies identified in this
systematic review that there is no one 'perfect' design for
measuring the incidence of schizophrenia – different
studies have different strengths. Most of the studies pro-
vide rates that are in reality the 'treated incidence' of schiz-
ophrenia (that is, the count of individuals who are
identified by services and treated). Factors related to serv-
ice availability and the pathways to care vary considera-
bly. Apart from the obvious issue of availability of
services, recent research has shown that community edu-
cation about psychosis can lead to sudden increases in the
number of 'new' cases presenting to services [197]. How-
ever, we can reasonably infer that the studies included in
this systematic review probably underestimate the true
(underlying) incidence of schizophrenia.
There are many additional analyses that could be under-
taken with these data. In future papers we plan to explore
the relationship between incidence rates and ecological
features of the catchment area (for example, population
age structure, social and financial indices). The impact of
age adjustment on the rates (which has been addressed in
previous narrative reviews [198]), will also be examined
more closely. However, in a commentary, Berlin [199]
cautions the scientist as follows: "Meta-analysis is like any
other form of data analysis in that it requires strict adher-
ence to methodological guidelines, careful planning, the
use of a priori definitions and analytic strategies, and
extremely careful interpretation that does not go beyond
the limits of the data" (p387). We endorse Berlin's
recommendations.
Conclusions
This systematic review of the incidence of schizophrenia
reveals a complex and varied epidemiological landscape
[5]. While the median incidence rate for persons was 15.2
per 100,000, the 10% to 90% quantiles cover over a five-
fold range of rates (7.7 to 43.0 per 100,000). The distribu-
tion is positively skewed, with many studies reporting
rates in the upper range. The incidence of schizophrenia is
higher in men compared to women, higher in urban sites
compared to mixed urban/rural sites, and higher in
migrants compared to native-born individuals.
Traditional Linnean taxonomy classifies living creatures
into various hierarchical categories. By way of analogy,
this systematic review has approached the broad genus of
studies related to the incidence of schizophrenia, and
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classified rates from these studies to the epidemiological
equivalents of species and subspecies. We believe that the
orderly array of these data has been informative and, in
some instances, visually appealing (like butterfly collec-
tions!). We encourage researchers to further explore these
data in order to help generate testable hypotheses.
Goethe noted that data are the natural enemy of hypoth-
eses. In a Darwinian sense, the provision of data alters the
landscape such that 'unfit' hypotheses should be less pros-
perous. In other words, the addition of new data should
assist in the culling of less heuristic hypotheses. By assem-
bling and sorting rates related to the incidence of schizo-
phrenia, we hope that we have enriched the
epidemiological environment and that these data will
facilitate the survival of the most heuristic hypotheses.
Competing interests
None declared.
Authors' contributions
JM conceived and supervised the study. All authors
assisted with design of the study, data extraction, and
writing up. DC supervised and carried out the statistical
analysis. All authors were involved in data management
and the preparation of the manuscript.
Additional files
(1) Glossary: Word document
(2) Quality Reporting Scale: Word document
(3) Additional figures: Word document
• Figure S1. Cumulative plots of the incidence rates per
100,000, by features of reporting by sex
• Figure S2. Cumulative plots of the incidence rates per
100,000, by tercile rank of the quality score
• Figure S3. Cumulative plots of the incidence rates per
100,000, by Case-Finding Method
• Figure S4. Cumulative plots of the incidence rates per
100,000, by Confirmation of Diagnosis
• Figure S5. Cumulative plots of the incidence rates per
100,000, by Diagnostic Assessment Method
• Figure S6. Cumulative plots of the incidence rates per
100,000, by Sex and Age Standardization
• Figure S7. Cumulative plots of the incidence rates per
100,000, by Age Range
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BMC Medicine 2004, 2 http://www.biomedcentral.com/1741-7015/2/13

• Figure S8. Cumulative plots of the incidence rates per • Table S14: Characteristics (quantiles and moments) of
100,000, by Years of Intake incidence rates per 100,000, by Age Range

(4) Description of studies: Word document • Table S15: Characteristics (quantiles and moments) of
incidence rates per 100,000, by year of first Intake
a. Table S1: Summary table of incidence of schizophrenia:
Core studies (6) Complete data set in Excel format.

b. Table S2: Summary table of incidence of schizophrenia: (7) Complete data set in Access format. (zipped).
Migrant studies
Additional material
c. Table S3: Birth cohort studies providing incidence in
person years, cumulative incidence or cumulative percent
Additional File 1
http://www.biomedcentral.com/imedia/1862872583417819/sup1.doc
d. Table S4: The incidence of schizophrenia in Other Spe- Click here for file
cial Groups [http://www.biomedcentral.com/content/supplementary/1741-
7015-2-13-S1.doc]
(5) Additional tables and detailed results: Word
document Additional File 2
http://www.biomedcentral.com/imedia/8656447533417738/sup2.doc
• Table S5: Characteristics (quantiles and moments) of Click here for file
[http://www.biomedcentral.com/content/supplementary/1741-
incidence rates per 100,000, for rates for persons, males 7015-2-13-S2.doc]
and females, and male to female rate ratio
Additional File 3
• Table S6: Characteristics (quantiles and moments) of http://www.biomedcentral.com/imedia/6800396953417826/sup3.doc
incidence rates per 100,000, by Sex and Urbanicity Click here for file
[http://www.biomedcentral.com/content/supplementary/1741-
• Table S7: Characteristics (quantiles and moments) of 7015-2-13-S3.doc]
incidence rates per 100,000, by Migrant Status, and
Migrant to Native-born rate ratio by sex Additional File 4
http://www.biomedcentral.com/imedia/1144262997341774/sup4.doc
Click here for file
• Table S8: Characteristics (quantiles and moments) of [http://www.biomedcentral.com/content/supplementary/1741-
incidence rates per 100,000, by Sex, and by features of 7015-2-13-S4.doc]
reporting by sex.
Additional File 5
• Table S9. Characteristics (quantiles and moments) of http://www.biomedcentral.com/imedia/1480669390341774/sup5.doc
incidence rates per 100,000, by terciles of the Quality Click here for file
[http://www.biomedcentral.com/content/supplementary/1741-
Score
7015-2-13-S5.doc]

• Table S10: Characteristics (quantiles and moments) of Additional File 6

incidence rates per 100,000, by Method of Finding Cases http://www.biomedcentral.com/imedia/1396785452341783/sup6.xls
Click here for file
• Table S11: Characteristics (quantiles and moments) of [http://www.biomedcentral.com/content/supplementary/1741-
incidence rates per 100,000, by Confirmation of 7015-2-13-S6.xls]
Diagnosis
Additional File 7
http://www.biomedcentral.com/imedia/1705991844341783/sup7.zip
• Table S12: Characteristics (quantiles and moments) of Click here for file
incidence rates per 100,000, by Diagnostic Assessment [http://www.biomedcentral.com/content/supplementary/1741-
Method 7015-2-13-S7.zip]

• Table S13: Characteristics (quantiles and moments) of

incidence rates per 100,000, by Sex and Age
Standardization Acknowledgements
The authors wish to express their gratitude to the following colleagues who
assisted in the search for data and translation of the studies: J Allardyce, P
Allebeck, G Andrews, M Balestrieri, N Beer, D Bhugra, M Biggs, J Boydell,

Page 17 of 22
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BMC Medicine 2004, 2
M Bresnahan, S Caleo, R Cochrane, T Crow, J Culberg, C D'Arcy, D Down-
ham, J Eagles, W Eaton, RW Grawe, V Folnegovic, Z Folnegovic, H Hafner,
G Harrison, C Harvey, QK Hii, F Hickling, W Iacono, M Isohanni, E Jacko,
A Jablensky, P Jorgensen, P Joyce, M Kawai, E Klaning, A Lesage, I Lynge, W
Mallett, O Mors, PB Mortensen, P Munk-Jorgensen, RM Murray, T Oldehin-
kel, A Preti, M Prince, A Rybak, R Scheurer, JP Selten, I Shvetson, E Susser,
J Suvisaari, N Takei, D Tantam, R Thara, EF Torrey, J van Os, D Walsh, and
Z Welham. The Stanley Medical Research Institute supported this project.
References
1. McGrath JJ: Gaining traction on the epidemiological landscape
of schizophrenia. Am J Epidemiol 2003, 158:291-300.
2. Eaton WW: Epidemiology of schizophrenia. Epidemiol Rev 1985,
7:105-126.
3. Eaton WW, Tien AY, Poeschla BD: Epidemiology of schizophre-
nia. In Advances in the Neurobiology of Schizophrenia Edited by: Den
Boer JA, Westenberg HGM, van Praag HM. John Wiley & Sons;
Oxford, UK; 1995.
4. Warner R, de Girolamo G: Schizophrenia Geneva: World Health
Organization; 1995.
5. Jablensky A: Schizophrenia: the epidemiological horizon. In
Schizophrenia Edited by: Hirsch SR, Weinberger DR. Oxford: Black-
well Science; 2003:203-231.
6. Breslow RA, Ross SA, Weed DL: Quality of reviews in
epidemiology. Am J Public Health 1998, 88:475-477.
7. Chalmers I, Haynes B: Reporting, updating, and correcting sys-
tematic reviews of the effects of health care. BMJ 1994,
309:862-865.
8. Egger M, Smith GD: Meta-Analysis. Potentials and promise. BMJ
1997, 315:1371-1374.
9. Mortensen PB, Pedersen CB, Westergaard T, Wohlfahrt J, Ewald H,
Mors O, Andersen PK, Melbye M: Effects of family history and
place and season of birth on the risk of schizophrenia. N Engl
J Med 1999, 340:603-608.
10. Susser E, Neugebauer R, Hoek HW, Brown AS, Lin S, Labovitz D,
Gorman JM: Schizophrenia after prenatal famine. Further
evidence. Arch Gen Psychiatry 1996, 53:25-31.
11. Selten JP, Brown AS, Moons KG, Slaets JP, Susser ES, Kahn RS: Pre-
natal exposure to the 1957 influenza pandemic and non-
affective psychosis in The Netherlands. Schizophr Res 1999,
38:85-91.
12. Cannon M, Jones PB, Murray RM: Obstetric complications and
schizophrenia: historical and meta-analytic review. Am J
Psychiatry 2002, 159:1080-1092.
13. Jablensky A, Sartorius N, Ernberg G, Anker M, Korten A, Cooper JE,
Day R, Bertelsen A: Schizophrenia: manifestations, incidence
and course in different cultures. A World Health Organiza-
tion ten-country study. Psychol Med Monogr Suppl 1992, 20:1-97.
14. Crow TJ: Schizophrenia as the price that homo sapiens pays
for language: a resolution of the central paradox in the origin
of the species. Brain Res Brain Res Rev 2000, 31:118-129.
15. Jablensky AV, Kalaydjieva LV: Genetic epidemiology of schizo-
phrenia: phenotypes, risk factors, and reproductive
behavior. Am J Psychiatry 2003, 160:425-429.
16. Leung A, Chue P: Sex differences in schizophrenia, a review of
the literature. Acta Psychiatr Scand Suppl 2000, 401:3-38.
17. Aleman A, Kahn RS, Selten JP: Sex differences in the risk of schiz-
ophrenia: evidence from meta-analysis. Arch Gen Psychiatry
2003, 60:565-571.
18. Castle DJ: Women and schizophrenia: an epidemiological per-
spective. In Women and schizophrenia Edited by: Castle DJ, McGrath
J, Kulkarni J. Cambridge: Cambridge University Press; 2000:19-33.
19. Faris REL, Dunham HW: Mental disorders in urban areas Chicago: Chi-
cago University Press; 1939.
20. Takei N, O'Callaghan E, Sham P, Glover G, Murray RM: Winter
birth excess in schizophrenia: its relationship to place of
birth. Schizophr Res 1992, 6:102.
21. Lewis G, David A, Andreasson S, Allebeck P: Schizophrenia and
city life. Lancet 1992, 340:137-140.
22. O'Callaghan E, Colgan K, Cotter D, Larkin C, Walsh D, Waddington
JL: Evidence for confinement of winter birth excess in schiz-
ophrenia to those born in cities. Schizophr Res 1992, 6:102.
http://www.biomedcentral.com/1741-7015/2/13
23. Marcelis M, Navarro-Mateu F, Murray R, Selten JP, Van Os J: Urban-
ization and psychosis: a study of 1942–1978 birth cohorts in
The Netherlands. Psychol Med 1998, 28:871-879.
24. Pedersen CB, Mortensen PB: Evidence of a dose-response rela-
tionship between urbanicity during upbringing and schizo-
phrenia risk. Arch Gen Psychiatry 2001, 58:1039-1046.
25. McMichael AJ: Human frontiers, environments and disease Cambridge:
Cambridge University Press; 2001.
26. Marcelis M, Takei N, Van Os J: Urbanization and risk of schizo-
phrenia: does the effect operate before or around the time
of illness onset? Psychol Med 1999, 29:1197-1203.
27. Odegard O: Emigration and insanity: a study of mental disease
among Norweigian-born population in Minnesota. Acta Psychi-
atrica et Neurologica Scandinavica 1932, 7(suppl 4):1-206.
28. Eaton W, Harrison G: Ethnic disadvantage and schizophrenia.
Acta Psychiatr Scand Suppl 2000, 102:38-43.
29. Harrison G: Searching for the causes of of schizophrenia: The
role of migrant studies. Schizophr Bull 1990, 16:663-671.
30. Aesop Study Team: Raised incidence of all psychosis in UK
migrant populations. Schizophr Res 2002, 53:33.
31. Selten JP, Veen N, Feller W, Blom JD, Schols D, Camoenie W,
Oolders J, van der Velden M, Hoek HW, Rivero VM, van der Graaf Y,
Kahn R: Incidence of psychotic disorders in immigrant groups
to The Netherlands. Br J Psychiatry 2001, 178:367-372.
32. Cantor-Graae E, Pedersen CB, McNeil TF, Mortensen PB: Migration
as a risk factor for schizophrenia: a Danish population-based
cohort study. Br J Psychiatry 2003, 182:117-122.
33. Zolkowska K, Cantor-Graae E, McNeil TF: Increased rates of psy-
chosis among immigrants to Sweden: is migration a risk fac-
tor for psychosis? Psychol Med 2001, 31:669-678.
34. McGrath J, El-Saadi O, Cardy S, Chapple B, Chant D, Mowry B:
Urban birth and migrant status as risk factors for psychosis:
an Australian case-control study. Soc Psychiatry Psychiatr Epidemiol
2001, 36:533-536.
35. Weyerer S, Hafner H: The high incidence of psychiatrically
treated disorders in the inner city of Mannheim. Susceptibil-
ity of German and foreign residents. Soc Psychiatry Psychiatr
Epidemiol 1992, 27:142-146.
36. Moher D, Olkin I: Meta-analysis of randomised controlled tri-
als. A concern for standards. JAMA 1995, 274:1962-1964.
37. Loney PL, Chambers LW, Bennett KJ, Roberts JG, Stratford PW:
Critical appraisal of the health research literature: Preva-
lence or incidence of a health problem. Chronic Dis Can 1998,
19:170-176.
38. Al-Jader LN, Newcombe RG, Hayes S, Murray A, Layzell J, Harper PS:
Developing a quality scoring system for epidemiological sur-
veys of genetic disorders. Clin Genet 2002, 62:230-234.
39. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D,
Moher D, Becker BJ, Sipe TA, Thacker SB: Meta-analysis of obser-
vational studies in epidemiology: a proposal for reporting.
Meta-analysis Of Observational Studies in Epidemiology
(MOOSE) group. JAMA 2000, 283:2008-2012.
40. Allardyce J, Morrison G, Van Os J, Kelly J, Murray RM, McCreadie RG:
Schizophrenia is not disappearing in south-west Scotland. Br
J Psychiatry 2000, 177:38-41.
41. Al Mousawi AH, Dunstan FD: Changes in the risk of schizophre-
nia in Scotland: is there an environmental factor? Schizophr Bull
1998, 24:529-535.
42. Suvisaari JM, Haukka JK, Tanskanen AJ, Lonnqvist JK: Decline in the
incidence of schizophrenia in Finnish cohorts born from 1954
to 1965. Arch Gen Psychiatry 1999, 56:733-740.
43. El-Saadi O, Welham J, Saha S, MaCaulay C, Collingwood L, Chant D,
McGrath JJ: The incidence and prevalence of schizophrenia:
preliminary results from a systematic review. Schizophr Res
2001, S49(Suppl):.
44. El-Saadi O, Welham J, Saha S, MaCaulay C, Collingwood L, Chant D,
Torrey EF, McGrath JJ: The incidence and prevalence of schizo-
phrenia: preliminary results from a systematic review. Schiz-
ophr Res 2002, S53(Suppl):S132-32.
45. Bhugra D, Hilwig M, Hossein B, Marceau H, Neehall J, Leff J, Mallett
R, Der G: First-contact incidence rates of schizophrenia in
Trinidad and one-year follow-up. Br J Psychiatry 1996,
169:587-592.
46. Mahy GE, Mallett R, Leff J, Bhugra D: First-contact incidence rate
of schizophrenia on Barbados. Br J Psychiatry 1999, 175:28-33.
Page 18 of 22
(page number not for citation purposes)
BMC Medicine 2004, 2
47. D'Arcy C, Rawson NSB, Lydick E, Epstein R: The epidemiology of
treated schizophrenia Saskatchewan 1976–1990. In World Psy-
chiatric Association, Section of Epidemiology and Community Psychiatry.
The Netherlands 1993.
48. Chowdhury AK: Admissions to an East Pakistan mental
hospital. Br J Psychiatry 1966, 112:65-68.
49. Messias E, Sampaio JJ, Messias NC, Kirkpatrick B: Epidemiology of
schizophrenia in Northeast Brazil. J Nerv Ment Dis 2000,
188:118-120.
50. Bland RC: Demographic aspects of functional psychoses in
Canada. Acta Psychiatr Scand 1977, 55:369-80.
51. Bland RC, Orn H: 14-year outcome in early schizophrenia. Acta
Psychiatr Scand 1978, 58:327-338.
52. Bland RC: Long term mental illness in Canada: an epidemio-
logical perspective on schizophrenia and affective disorders.
Can J Psychiatry 1984, 29:242-246.
53. Iacono WG, Beiser M: Are males more likely than females to
develop schizophrenia? Am J Psychiatry 1992, 149:1070-1074.
54. Nicole L, Lesage A, Lalonde P: Lower incidence and increased
male:female ratio in schizophrenia. Br J Psychiatry 1992,
161:556-557.
55. Ma SP: [An epidemiologic investigation of psychoses in
Laoshan County of Qingdao]. Zhonghua Shen Jing Jing Shen Ke Za
Zhi 1980, 13:22-23.
56. Chen CH: [Incidence and prevalence of schizophrenia in a
community mental health service from 1975 to 1981]. Zhon-
ghua Shen Jing Jing Shen Ke Za Zhi 1984, 17:321-324.
57. Yucun S, Weixi Z, Lian S, Xiaoling Y, Yuhua C, Dongfeng Z, Hengyao
S, Entao S: A survey of mental disorders in a suburb of Beijing.
Int J Ment Health 1988, 16:75-80.
58. Folnegovic Z, Folnegovic-Smalc V, Kulcar Z: The incidence of
schizophrenia in Croatia. Br J Psychiatry 1990, 156:363-365.
59. J Nielsen J: The Samso project from 1957 to 1974. Acta Psychiatr
Scand 1976, 54:198-222.
60. Nielsen J, Nielsen JA: A census study of mental illness in Samso.
Psychol Med 1977, 7:491-503.
61. Jorgensen P: Delusional psychosis. Hospital incidence, symp-
toms and classification. Acta Psychiatr Scand 1986, 74:18-23.
62. Munk-Jorgensen P: Decreasing first-admission rates of schizo-
phrenia among males in Denmark from 1970 to 1984.
Changing diagnostic patterns? Acta Psychiatr Scand 1986,
73:645-650.
63. Munk-Jorgensen P, Mortensen PB: Incidence and other aspects of
the epidemiology of schizophrenia in Denmark, 1971–87. Br J
Psychiatry 1992, 161:489-495.
64. Munk-Jorgensen P, Lutzhoft JH, Jensen J, Stromgren E: Trends in
psychiatric hospitalization in Denmark: a 10-year register-
based investigation. Acta Psychiatr Scand 1992, 86:79-83.
65. Mors O, Sorensen LV: Incidence and comorbidity of psychiatric
disorders from a well-defined catchment area in Denmark.
Eur Psychiatry 1993, 8:193-199.
66. Lynge I, Jacobsen J: Schizophrenia in Greenland: a follow-up
study. Acta Psychiatr Scand 1995, 91:414-422.
67. Lynge I, Mortensen PB, Munk-Jorgensen P: Mental disorders in the
Greenlandic population. A register study. Int J Circumpolar
Health 1999, 58:188-197.
68. Schelin EM, Munk-Jorgensen P, Olesen AV, Gerlach J: Regional dif-
ferences in schizophrenia incidence in Denmark. Acta Psychiatr
Scand 2000, 101:293-299.
69. Niskanen P, Achte KA: The course and prognosis of schizo-
phrenic psychoses in helsinki, a comparative study of first
admissions in 1960 and 1965. Helsinki; Helsinki University Central
Hospital 1972.
70. Salokangas RK: First admissions for psychosis in Turku. A time
trend study. Acta Psychiatr Scand 1979, 60:249-262.
71. Kuusi K: Prognosis of schizophrenia psychosis in Helsinki in
1975–1983. Monographs of Psychiatria Fennica 1986, 13:.
72. Salokangas RK: First-contact rate for schizophrenia in commu-
nity psychiatric care. Consideration of the oestrogen
hypothesis. Eur Arch Psychiatry Clin Neurosci 1993, 242:337-346.
73. Lehtinen V, Veijola J, Lindholm T, Moring J, Puukka P, Vaisanen E: Inci-
dence of mental disorders in the Finnish UKKI study. Br J
Psychiatry 1996, 168:672-678.
74. van Os J, Galdos P, Lewis G, Bourgeois M, Mann A: Schizophrenia
sans frontieres: concepts of schizophrenia among French
and British psychiatrists. BMJ 1993, 307:489-492.
http://www.biomedcentral.com/1741-7015/2/13
75. Hafner H, an der Heiden W: The contribution of European case
registers to research on schizophrenia. Schizophr Bull 1986,
12:26-51.
76. Loffler W, Hafner H: Ecological pattern of first admitted schiz-
ophrenics in two German cities over 25 years. Soc Sci Med
1999, 49:93-108.
77. Helgason L: Psychiatric services and mental illness in Iceland.
Incidence study (1966–1967) with 6–7 year follow-up. Acta Psy-
chiatr Scand Suppl 1977:1-140.
78. Rajkumar S, Padmavati R, Thara R, Sarada Menon M: Incidence of
shizophrenia in an urban community in Madras. Indian J
Psychiatry 1993, 35:18-21.
79. Walsh D: The ups and downs of schizophrenia in Ireland. Ir J
Psychiatry 1992, 13:12-16.
80. Walsh D: Mental illness in Dublin – first admissions. Br J
Psychiatry 1969, 115:449-456.
81. O'Hare A, Walsh D: Further data on activities of Irish psychiat-
ric hospitals and units, 1965–1969. J Ir Med Assoc 1974, 67:57-63.
82. ni Nuallain M, O'Hare A, Walsh D, Blake B, Halpenny JN, O'Brien PF:
The incidence of mental illness in Ireland – patients contact-
ing psychiatric services in three Irish counties. Ir J Psychiatry
1984, 5:23-29.
83. Repetto F, Formigaro F, Ferrari P, Frascaroli G, Lora A, Magnani G,
Mastroeni A, Travasso B, Morosini P: [Estimate of the hospital
incidence of schizophrenia in Lombardy]. Epidemiol Prev 1988,
10:20-25.
84. Tansella M, Balestrieri M, Meneghelli M, Micciolo Rl: Trends in the
provision of psychiatric care 1979–1988. Psychol Med 1991,
19:1-54.
85. de Salvia D, Barbato A, Salvo P, Zadro F: Prevalence and incidence
of schizophrenic disorders in Portogruaro. An Italian case
register study. J Nerv Ment Dis 1993, 181:275-82.
86. Mata I, Beperet M, Madoz V, Psicost Y: Prevalence and incidence
of schizophrenia in Navarra. Anales Sis San Navara 2000,
23:29-36.
87. Preti A, Miotto P: Increase in first admissions for schizophrenia
and other major psychoses in Italy. Psychiatry Res 2000,
94:139-152.
88. Hickling FW, Rodgers-Johnson P: The incidence of first contact
schizophrenia in Jamaica. Br J Psychiatry 1995, 167:193-196.
89. Ohta Y, Nakane Y, Nishihara J, Takemoto T: Ecological structure
and incidence rates of schizophrenia in Nagasaki City. Acta
Psychiatr Scand 1992, 86:113-120.
90. Giel R, Sauer HC, Slooff CJ, Wiersma D: Over de epidemiologie
van functionele psychosen en invaliditeit [Epidemiological
observations on schizophrenia and disability in the
Netherlands]. Tijdschrift voor psychiatrie 1980, 22:710-722.
91. Oldehinkel AJ, Giel R: Time trends in the care-based incidence
of schizophrenia. Br J Psychiatry 1995, 167:777-782.
92. Peen J, Dekker J: Admission rates for schizophrenia in The
Netherlands: an urban/rural comparison. Acta Psychiatr Scand
1997, 96:301-305.
93. van Os J, Driessen G, Gunther N, Delespaul P: Neighbourhood
variation in incidence of schizophrenia. Evidence for person-
environment interaction. Br J Psychiatry 2000, 176:243-248.
94. Joyce PR: Changing trends in first admissions and readmis-
sions for mania and schizophrenia in New Zealand, 1974 to
1984. Aust N Z J Psychiatry 1987, 21:82-86.
95. Johannessen JO: Schizofreni-forekomst i et norsk fylke,
Rogaland. Nord Psykiatr Tidsskr 1985, 39:217-223.
96. Grawe R, Levander S, Krueger M: Incidence, clinical characteris-
tics, and short-term outcome of first-episode schizophrenia.
Nordisk Psykiatrisk Tidsskrift 1991, 45:383-390.
97. Lieberman YI: [The incidence of schizophrenia (materials
from a clinico-epidemiologic study)]. Zh Nevropatol Psikhiatr Im
S S Korsakova 1974, 74:1224-1233.
98. Rotshtein VG: [Incidence of paranoid schizophrenia]. Zh Nev-
ropatol Psikhiatr Im S S Korsakova 1982, 82:91-98.
99. Vul FR, Mishkind AD, Gil'burd OA, Vorobeichik DA: Clinico-epide-
miologic characteristics of mental diseases in one of the
regions of western Siberia. Zh Nevropatol Psikhiatr Im S S Korsakova
1988, 88:111-116.
100. Tsoi WF, Chen AJ: New admissions to Woodbridge Hospital
1975 with special reference to schizophrenia. Ann Acad Med
Singapore 1979, 8:275-279.
Page 19 of 22
(page number not for citation purposes)
BMC Medicine 2004, 2
101. Vazquez-Barquero JL, Cuesta Nunez MJ, de la Varga M, Herrera Cas-
tanedo S, Gaite L, Arenal A: The Cantabria first episode schizo-
phrenia study: a summary of general findings. Acta Psychiatr
Scand 1995, 91:156-162.
102. Osby U, Hammar N, Brandt L, Wicks S, Thinsz Z, Ekbom A, Sparen
P: Time trends in first admissions for schizophrenia and par-
anoid psychosis in Stockholm County, Sweden. Schizophr Res
2001, 47:247-254.
103. Svedberg B, Mesterton A, Cullberg J: First-episode non-affective
psychosis in a total urban population: a 5-year follow-up. Soc
Psychiatry Psychiatr Epidemiol 2001, 36:332-337.
104. Neehall J: An analysis of psychiatric inpatient admissions from
a defined geographic catchment area over a one-year
period. West Indian Med J 1991, 40:16-21.
105. Adelstein AM, Downham DY, Stein Z, Susser MW: The epidemiol-
ogy of mental illness in an English city: inceptions recognized
by Salford Psychiatric services. Soc Psychiatry 1968, 3:47-59.
106. Mezey AG, Evans E: Psychiatric in-patients and out-patients in
a London borough. Br J Psychiatry 1971, 118:609-616.
107. Eagles JM, Whalley LJ: Decline in the diagnosis of schizophrenia
among first admissions to Scottish mental hospitals from
1969–78. Br J Psychiatry 1985, 146:151-154.
108. Giggs JA: Mental disorders and ecological structure in
Nottingham. Soc Sci Med 1986, 23:945-961.
109. Eagles JM, Hunter D, McCance C: Decline in the diagnosis of
schizophrenia among first contacts with psychiatric services
in north-east Scotland, 1969–1984. Br J Psychiatry 1988,
152:793-798.
110. de Alarcon JG, Seagroatt V: Trends in schizophrenia. Lancet 1990,
335:852-853.
111. Der G, Gupta S, Murray RM: Is schizophrenia disappearing? Lan-
cet 1990, 335:513-516.
112. Prince M, Phelan M: Trends in Schizophrenia. Lancet 1990,
335:851-852.
113. Bamrah JS, Freeman HL, Goldberg DP: Epidemiology of schizo-
phrenia in Salford, 1974–84. Changes in an urban community
over ten years. Br J Psychiatry 1991, 159:802-810.
114. Harrison G, Cooper JE, Gancarczyk R: Changes in the administra-
tive incidence of schizophrenia. Br J Psychiatry 1991, 159:811-816.
115. Ring N, Tantam D, Montague L, Newby D, Black D, Morris J: Gender
differences in the incidence of definite schizophrenia and
atypical psychosis – focus on negative symptoms of
schizophrenia. Acta Psychiatr Scand 1991, 84:489-496.
116. Geddes JR, Black RJ, Whalley LJ, Eagles JM: Persistence of the
decline in the diagnosis of schizophrenia among first admis-
sions to Scottish hospitals from 1969 to 1988. Br J Psychiatry
1993, 163:620-626.
117. Castle DJ, Wessely S, Murray RM: Sex and schizophrenia: effects
of diagnostic stringency, and association with premorbid
variables. Br J Psychiatry 1993, 162:658-664.
118. Kendell RE, Malcolm DE, Adams W: The problem of detecting
changes in the incidence of schizophrenia. Br J Psychiatry 1993,
162:212-218.
119. Goldacre M, Shiwach R, Yeates D: Estimating incidence and
prevalence of treated psychiatric disorders from routine sta-
tistics: the example of schizophrenia in Oxfordshire. J Epide-
miol Community Health 1994, 48:318-322.
120. Prince M, Phelan M: Invisible schizophrenia: A postal survey of
the incidence and management of new cases of schizophre-
nia in primary care. J Ment Health 1994, 3:91-98.
121. van Os J, Castle DJ, Takei N, Der G, Murray RM: Psychotic illness
in ethnic minorities: clarification from the 1991 census. Psy-
chol Med 1996, 26:203-208.
122. McNaught AS, Jeffreys SE, Harvey CA, Quayle AS, King MB, Bird AS:
The Hampstead Schizophrenia Survey 1991. II: Incidence
and migration in inner London. Br J Psychiatry 1997, 170:307-311.
123. Cavanagh JT, Shajahan PM: Increasing rates of hospital admis-
sion for men with major mental illnesses: data from Scottish
mental health units, 1980–1995. Acta Psychiatr Scand 1999,
99:353-359.
124. Boydell J, van Os J, McKenzie K, Allardyce J, Goel R, McCreadie RG,
Murray RM: Incidence of schizophrenia in ethnic minorities in
London: ecological study into interactions with
environment. BMJ 2001, 323:1336-1338.
125. Dunham HW: Community and Schizophrenia: an epidemiological analysis
Detroit, Michigan: Wayne State University Press; 1965.
http://www.biomedcentral.com/1741-7015/2/13
126. Eaton WW: Residence, social class, and schizophrenia. J Health
Soc Behav 1974, 15:289-299.
127. Tien AY, Eaton WW: Psychopathologic precursors and socio-
demographic risk factors for the schizophrenia syndrome.
Arch Gen Psychiatry 1992, 49:37-46.
128. Krupinski J, Cochrane R: Migration and mental health – a com-
parative study. J Int Studies 1980, 1:49-57.
129. Selten JP, Sijben N: First admission rates for schizophrenia in
immigrants to The Netherlands. The Dutch National
Register. Soc Psychiatry Psychiatr Epidemiol 1994, 29:71-77.
130. Selten JP, Slaets JP, Kahn RS: Schizophrenia in Surinamese and
Dutch Antillean immigrants to The Netherlands: evidence of
an increased incidence. Psychol Med 1997, 27:807-811.
131. Hemsi LK: Psychiatric morbidity of West Indian immigrants.
Soc Psychiatry 1967, 2:95-100.
132. Giggs J: High rates of schizophrenia among immigrants in
Nottingham. Nurs Times 1973, 69:1210-1212.
133. Rwegellera GG: Psychiatric morbidity among West Africans
and West Indians living in London. Psychol Med 1977, 7:317-329.
134. Carpenter L, Brockington IF: A study of mental illness in Asians,
West Indians and Africans living in Manchester. Br J Psychiatry
1980, 137:201-205.
135. Hitch PJ, Rack PH: Mental illness among Polish and Russian ref-
ugees in Bradford. Br J Psychiatry 1980, 137:206-211.
136. Dean G, Walsh D, Downing H, Shelley E: First admissions of
native-born and immigrants to psychiatric hospitals in
South-East England 1976. Br J Psychiatry 1981, 139:506-512.
137. Dean G, Downing H, Shelley E: First admissions to psychiatric
hospitals in south-east England in 1976 among immigrants
from Ireland. Br Med J (Clin Res Ed) 1981, 282:1831-1833.
138. Cochrane R, Bal SS: Migration and schizophrenia: an examina-
tion of five hypotheses. Soc Psychiatry 1987, 22:181-191.
139. McGovern D, Cope RV: First psychiatric admission rates of first
and second generation Afro Caribbeans. Soc Psychiatry 1987,
22:139-149.
140. Harrison G, Owens D, Holton A, Neilson D, Boot D: A prospective
study of severe mental disorder in Afro-Caribbean patients.
Psychol Med 1988, 18:643-657.
141. Cochrane R, Bal SS: Mental hospital admission rates of immi-
grants to England: a comparison of 1971 and 1981. Soc Psychi-
atry Psychiatr Epidemiol 1989, 24:2-11.
142. Castle D, Wessely S, Der G, Murray RM: The incidence of opera-
tionally defined schizophrenia in Camberwell, 1965–84. Br J
Psychiatry 1991, 159:790-794.
143. Thomas CS, Stone K, Osborn M, Thomas PF, Fisher M: Psychiatric
morbidity and compulsory admission among UK-born Euro-
peans, Afro-Caribbeans and Asians in central Manchester. Br
J Psychiatry 1993, 163:91-99.
144. King M, E Coker M, Leavey G, Hoare A, Johnson-Sabine E: Incidence
of psychotic illness in London: comparison of ethnic groups.
BMJ 1994, 309:1115-1119.
145. Bhugra D, Leff J, Mallett R, Der G, Corridan B, Rudge S: Incidence
and outcome of schizophrenia in whites, African-Caribbeans
and Asians in London. Psychol Med 1997, 27:791-798.
146. Harrison G, Glazebrook C, Brewin J, Cantwell R, Dalkin , Fox R, Jones
P, Medley I: Increased incidence of psychotic disorders in
migrants from the Caribbean to the United Kingdom. Psychol
Med 1997, 27:799-806.
147. Goater N, King M, Cole E, Leavey G, Johnson-Sabine E, Blizard R,
Hoar A: Ethnicity and outcome of psychosis. Br J Psychiatry 1999,
175:34-42.
148. Malzberg B: Internal migration and mental disease among the
white population of New York state, 1960–1961. Int J Soc
Psychiatry 1967, 13:184-191.
149. Goldstein G, Hall W, Andrews G: The incidence of schizophrenia
in New South Wales, Australia. A psychiatric register study.
Acta Psychiatr Scand 1984, 70:220-227.
150. Jones IH, Kirkby KC, Hay DA, Daniels BA, Longmore LM: Decline in
diagnoses of schizophrenia in Tasmania during the period
1965–1990. Acta Psychiatr Scand 1997, 95:13-18.
151. Brennan PA, Mednick SA, Hodgins S: Major mental disorders and
criminal violence in a Danish birth cohort. Arch Gen Psychiatry
2000, 57:494-500.
152. Haukka J, Suvisaari J, Varilo T, Lonnqvist J: Regional variation in
the incidence of schizophrenia in Finland: a study of birth
Page 20 of 22
(page number not for citation purposes)
BMC Medicine 2004, 2
cohorts born from 1950 to 1969. Psychol Med 2001,
31:1045-1053.
153. Makikyro T, Isohanni M: Is a child's risk of early onset schizo-
phrenia increased in the highest social class? Schizophr Res
1997, 23:245-252.
154. Rasanen S, Veijola J, Hakko H, Joukamaa M, Isohanni M: Gender dif-
ferences in incidence and age at onset of DSM-III-R schizo-
phrenia: Preliminary results of the Northern Finland 1966
birth cohort study. Schizophr Res 1999, 37:197-198.
155. Wahlbeck K, Forsen T, Osmond C, Barker DJ, Eriksson JG: Associ-
ation of schizophrenia with low maternal body mass index,
small size at birth, and thinness during childhood. Arch Gen
Psychiatry 2001, 58:48-52.
156. Davidson M, Reichenberg A, Rabinowitz J, Weiser M, Kaplan Z, Mark
M: Behavioral and intellectual markers for schizophrenia in
apparently healthy male adolescents. Am J Psychiatry 1999,
156:1328-1335.
157. Malaspina D, Harlap S, Fennig S, Heiman D, Nahon D, Feldman D,
Susser ES: Advancing paternal age and the risk of
schizophrenia. Arch Gen Psychiatry 2001, 58:361-367.
158. Balestrieri M, Rucci P, Nicolaou S: Gender-specific decline and
seasonality of births in operationally defined schizophrenics
in Italy. Schizophr Res 1997, 27:73-81.
159. Malmberg A, Lewis G, David A, Allebeck P: Premorbid adjustment
and personality in people with schizophrenia. Br J Psychiatry
1998, 172:308-313.
160. Crow TJ, Done DJ: Prenatal exposure to influenza does not
cause schizophrenia. Br J Psychiatry 1992, 161:390-393.
161. Jones P, Rodgers B, Murray R, Marmot M: Child development risk
factors for adult schizophrenia in the British 1946 birth
cohort. Lancet 1994, 344:1398-1402.
162. Takei N, Lewis G, Sham PC, Murray RM: Age-period-cohort anal-
ysis of the incidence of schizophrenia in Scotland. Psychol Med
1996, 26:963-973.
163. Bresnahan MA, Brown AS, Schaefer CA, Begg MD, Wyatt RJ, Susser
ES: Incidence and cumulative risk of treated schizophrenia in
the prenatal determinants of schizophrenia study. Schizophr
Bull 2000, 26:297-308.
164. Cannon TD, Rosso IM, Bearden CE, Sanchez LE, Hadley T: A pro-
spective cohort study of neurodevelopmental processes in
the genesis and epigenesis of schizophrenia. Dev Psychopathol
1999, 11:467-485.
165. Zornberg GL, Buka SL, Tsuang MT: Hypoxic-ischemia-related
fetal/neonatal complications and risk of schizophrenia and
other nonaffective psychoses: a 19-year longitudinal study.
Am J Psychiatry 2000, 157:196-202.
166. Alberdi F: Psychiatric admissions among the deaf population
in Denmark. Nord J Psychiatry 1996, 50:387-394.
167. Klaning U, Mortensen PB, Kyvik KO: Increased occurrence of
schizophrenia and other psychiatric illnesses among twins. Br
J Psychiatry 1996, 168:688-692.
168. Eaton WW, Levav I: Schizophrenia, social class and ethnic dis-
advantage. A study of first hospitalization among Israeli-
born Jews. Isr J Psychiatry Relat Sci 1982, 19:289-302.
169. Raman AC, Murphy HB: Failure of traditional prognostic indica-
tions in Afro-Asian psychotics: results of a long-term follow-
up survey. J Nerv Ment Dis 1972, 154:238-247.
170. Kelly R: Mental illness in the Maori population of New
Zealand. Acta Psychiatr Scand 1973, 49:722-734.
171. Noreik K, Odegard O: Psychoses in Norwegians with a back-
ground of higher education. Br J Psychiatry 1966, 112:43-55.
172. Nica-Udangiu S: Epidemiologic aspects of schizophrenias,
schizotypal disorders and schizoaffective psychoses in the
student population. Neurol Psychiatr (Bucur) 1983, 21:115-120.
173. Gavrilov SI, Kirzhanova VV: [Incidence of mental disorders
among the late middle-aged and elderly population (accord-
ing to the primary registration data of the psychoneurologic
institutions of Moscow)]. Zh Nevropatol Psikhiatr Im S S Korsakova
1983, 83:1338-1345.
174. Kendler KS, Pedersen NL, Farahmand BY, Persson PG: The treated
incidence of psychotic and affective illness in twins compared
with population expectation: a study in the Swedish Twin
and Psychiatric Registries. Psychol Med 1996, 26:1135-1144.
175. Loganovsky KN, Loganovskaja TK: Schizophrenia spectrum dis-
orders in persons exposed to ionizing radiation as a result of
the Chernobyl accident. Schizophr Bull 2000, 26:751-773.
http://www.biomedcentral.com/1741-7015/2/13
176. Copeland JR, Dewey ME, Scott A, Gilmore C, Larkin BA, Cleave N,
McCracken CF, McKibbin PE: Schizophrenia and delusional dis-
order in older age: community prevalence, incidence,
comorbidity, and outcome. Schizophr Bull 1998, 24:153-161.
177. Reeves SJ, Sauer J, Stewart R, Granger A, Howard RJ: Increased
first-contact rates for very-late-onset schizophrenia-like psy-
chosis in African- and Caribbean-born elders. Br J Psychiatry
2001, 179:172-174.
178. Castle DJ, Murray RM: The epidemiology of late-onset
schizophrenia. Schizophr Bull 1993, 19:691-700.
179. Babigian HM: Schizophrenia: epidemiology. In Comprehensive text-
book of psychiatry Volume 2. 3rd edition. Edited by: Freedman AM, Kap-
lan HI, Sadock BJ. Baltimore/London: Williams & Wilkins;
1980:860-866.
180. Allardyce J, Boydell J, Van Os J, Morrison G, Castle D, Murray RM,
McCreadie RG: Comparison of the incidence of schizophrenia
in rural Dumfries and Galloway and urban Camberwell. Br J
Psychiatry 2001, 179:335-339.
181. Brewin J, Cantwell R, Dalkin T, Fox R, Medley I, Glazebrook C,
Kwiecinski R, Harrison G: Incidence of schizophrenia in Not-
tingham. A comparison of two cohorts, 1978–80 and 1992–
94. Br J Psychiatry 1997, 171:140-144.
182. Cooper JE: The incidence of schizophrenia in Nottingham. Br
J Psychiatry 1987, 151:619-626.
183. Dauncey K, Giggs J, Baker K, Harrison G: Schizophrenia in Not-
tingham: lifelong residential mobility of a cohort. Br J Psychiatry
1993, 163:613-619.
184. Joensen S, Wang AG: First admissions for psychiatric disorders.
A comparison between the Faroe Islands and Denmark. Acta
Psychiatr Scand 1983, 68:66-71.
185. McCabe MS: Demographic differences in functional psychoses.
Br J Psychiatry 1975, 127:320-323.
186. Munk-Jorgensen P: Schizophrenia in Denmark. Incidence and
utilization of psychiatric institutions. Acta Psychiatr Scand 1986,
73:172-180.
187. Munk-Jorgensen P: First-admission rates and marital status of
schizophrenics. Acta Psychiatr Scand 1987, 76:210-216.
188. Munk-Jorgensen P, Jorgensen P: Decreasing rates of first-admis-
sion diagnoses of schizophrenia among females in Denmark
1970–84. Acta Psychiatr Scand 1986, 74:379-383.
189. Munk-Jorgensen P, Mortensen PB: Is schizophrenia really on the
decrease? Eur Arch Psychiatry Clin Neurosci 1993, 242:244-247.
190. Palmquist J, Wang AG: Schizophrenia in the Faroe Islands. Nord
J Psychiatry 1997, 51:351-357.
191. Wig NN, Varma VK, Mattoo SK, Behere PB, Phookan HR, Misra AK,
Srinivasa MR, Tripathi BM, Menon DK: An Incidence Study of
Schizophrenia in India. Indian J Psychiatry 1993, 35:11-17.
192. de Alarcon JG, Sainsbury P, Costain WR: Incidence of referred
mental illness in Chichester and Salisbury. Psychol Med 1975,
5:32-54.
193. Eaton WW, Mortensen PB, Frydenberg M: Obstetric factors,
urbanization and psychosis. Schizophr Res 2000, 43:117-123.
194. Karvonen M, Tuomilehto J, Libman I, LaPorte R: A review of the
recent epidemiological data on the worldwide incidence of
type 1 (insulin-dependent) diabetes mellitus. World Health
Organization DIAMOND Project Group. Diabetologia 1993,
36:883-892.
195. Isohanni M, Jones PB, Moilanen K, Rantakallio P, Veijola J, Oja H,
Koiranen M, Jokelainen J, Croudace T, Jarvelin M: Early develop-
mental milestones in adult schizophrenia and other psycho-
ses. A 31-year follow-up of the Northern Finland 1966 Birth
Cohort. Schizophr Res 2001, 52:1-19.
196. Wyatt RJ, Susser ES: U.S. birth cohort studies of schizophrenia:
a sea change. Schizophr Bull 2000, 26:255-256.
197. Friis S, Larsen TK, Melle I, Opjordsmoen S, Johannessen JO, Haahr U,
Simonsen E, Rund BR, Vaglum P, McGlashan T: Methodological pit-
falls in early detection studies – the NAPE Lecture 2002.
Nordic Association for Psychiatric Epidemiology. Acta Psychi-
atr Scand 2003, 107:3-9.
198. Yolles SF, Kramer M: Vital Statistics. In The Schizophrenic Syndrome
Edited by: Bellak L. New York: Grune and Stratton; 1969:66-113.
199. Berlin JA: Invited commentary: benefits of heterogeneity in
meta-analysis of data from epidemiologic studies. Am J
Epidemiol 1995, 142:383-387.
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(page number not for citation purposes)
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